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Duggins-Warf M, Ghalali A, Sesen J, Martinez T, Fehnel KP, Pineda S, Zurakowski D, Smith ER. Disease specific urinary biomarkers in the central nervous system. Sci Rep 2023; 13:19244. [PMID: 37935834 PMCID: PMC10630515 DOI: 10.1038/s41598-023-46763-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/04/2023] [Indexed: 11/09/2023] Open
Abstract
Urinary biomarkers can diagnose and monitor pathophysiologic conditions in the central nervous system (CNS). However, focus is often on single diseases, with limited data on discriminatory capability of this approach in a general setting. Here, we demonstrate that different classes of CNS disease exhibit distinct biomarker patterns, evidence of disease-specific "fingerprinting." Urine from 218 patients with pathology-confirmed tumors or cerebrovascular disease, controls (n = 33) were collected. ELISA and/or bead-based multiplexing quantified levels of 21 putative urinary biomarkers. Analysis identified biomarkers capable of distinguishing each disease from controls and other diseases. Mann-Whitney U tests identified biomarkers with differential expression between disease types and controls (P ≤ 0.001). Subsequent receiver-operating characteristic (ROC) analyses revealed distinguishing biomarkers with high sensitivity and specificity. Areas under the curve (AUCs) ranged 0.8563-1.000 (P values ≤ 0.0003), sensitivities ranged 80.00-100.00%, and specificities ranged 80.95-100.00%. These data demonstrate proof-of-principle evidence that disease-specific urinary biomarker signatures exist. In contrast to non-specific responses to ischemia or injury, these results suggest that urinary biomarkers accurately reflect unique biological processes distinct to different diseases. This work can be used to generate disease-specific panels for enhancing diagnosis, assisting less-invasive follow-up and herald utility by revealing putative disease-specific therapeutic targets.
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See AP, Smith ER. Evolution of clinical and translational advances in the management of pediatric arteriovenous malformations. Childs Nerv Syst 2023; 39:2807-2818. [PMID: 37462811 DOI: 10.1007/s00381-023-06077-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/09/2023] [Indexed: 10/29/2023]
Abstract
Arteriovenous malformations (AVMs) represent one of the most challenging diagnoses in pediatric neurosurgery. Until recently, the majority of AVMs was only identified after hemorrhage and primarily treated with surgery. However, recent advances in a wide range of fields-imaging, surgery, interventional radiology, radiation therapy, and molecular biology-have profoundly advanced the understanding and therapy of these complex lesions. Here we review the progress made in pediatric AVMs with a specific focus on innovations relevant to clinical care.
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Aldana PR, Pederson JM, Smith ER. Comment on: Highlight: Is smoke the signal for surgery? Should the moyamoya syndrome "puff of smoke" trigger cerebral revascularization surgery in children with sickle cell disease? Pediatr Blood Cancer 2023; 70:e30520. [PMID: 37376949 DOI: 10.1002/pbc.30520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023]
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Pinard A, Ye W, Fraser SM, Rosenfeld JA, Pichurin P, Hickey SE, Guo D, Cecchi AC, Boerio ML, Guey S, Aloui C, Lee K, Kraemer M, Alyemni SO, Bamshad MJ, Nickerson DA, Tournier-Lasserve E, Haider S, Jin SC, Smith ER, Kahle KT, Jan LY, He M, Milewicz DM. Rare variants in ANO1, encoding a calcium-activated chloride channel, predispose to moyamoya disease. Brain 2023; 146:3616-3623. [PMID: 37253099 PMCID: PMC10473557 DOI: 10.1093/brain/awad172] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/24/2023] [Accepted: 04/16/2023] [Indexed: 06/01/2023] Open
Abstract
Moyamoya disease, a cerebrovascular disease leading to strokes in children and young adults, is characterized by progressive occlusion of the distal internal carotid arteries and the formation of collateral vessels. Altered genes play a prominent role in the aetiology of moyamoya disease, but a causative gene is not identified in the majority of cases. Exome sequencing data from 151 individuals from 84 unsolved families were analysed to identify further genes for moyamoya disease, then candidate genes assessed in additional cases (150 probands). Two families had the same rare variant in ANO1, which encodes a calcium-activated chloride channel, anoctamin-1. Haplotype analyses found the families were related, and ANO1 p.Met658Val segregated with moyamoya disease in the family with an LOD score of 3.3. Six additional ANO1 rare variants were identified in moyamoya disease families. The ANO1 rare variants were assessed using patch-clamp recordings, and the majority of variants, including ANO1 p.Met658Val, displayed increased sensitivity to intracellular Ca2+. Patients harbouring these gain-of-function ANO1 variants had classic features of moyamoya disease, but also had aneurysm, stenosis and/or occlusion in the posterior circulation. Our studies support that ANO1 gain-of-function pathogenic variants predispose to moyamoya disease and are associated with unique involvement of the posterior circulation.
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Aldana PR, Hanel RA, Piatt J, Han SH, Bansal MM, Schultz C, Gauger C, Pederson JM, Iii JCW, Hulbert ML, Jordan LC, Qureshi A, Garrity K, Robert AP, Hatem A, Stein J, Beydler E, Adelson PD, Greene S, Grabb P, Johnston J, Lang SS, Leonard J, Magge SN, Scott A, Shah S, Smith ER, Smith J, Strahle J, Vadivelu S, Webb J, Wrubel D. Cerebral revascularization surgery reduces cerebrovascular events in children with sickle cell disease and moyamoya syndrome: Results of the stroke in sickle cell revascularization surgery retrospective study. Pediatr Blood Cancer 2023; 70:e30336. [PMID: 37057741 DOI: 10.1002/pbc.30336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Recent studies suggest that cerebral revascularization surgery may be a safe and effective therapy to reduce stroke risk in patients with sickle cell disease and moyamoya syndrome (SCD-MMS). METHODS We performed a multicenter, retrospective study of children with SCD-MMS treated with conservative management alone (conservative group)-chronic blood transfusion and/or hydroxyurea-versus conservative management plus surgical revascularization (surgery group). We monitored cerebrovascular event (CVE) rates-a composite of strokes and transient ischemic attacks. Multivariable logistic regression was used to compare CVE occurrence and multivariable Poisson regression was used to compare incidence rates between groups. Covariates in multivariable models included age at treatment start, age at moyamoya diagnosis, antiplatelet use, CVE history, and the risk period length. RESULTS We identified 141 patients with SCD-MMS, 78 (55.3%) in the surgery group and 63 (44.7%) in the conservative group. Compared with the conservative group, preoperatively the surgery group had a younger age at moyamoya diagnosis, worse baseline modified Rankin scale scores, and increased prevalence of CVEs. Despite more severe pretreatment disease, the surgery group had reduced odds of new CVEs after surgery (odds ratio = 0.27, 95% confidence interval [CI] = 0.08-0.94, p = .040). Furthermore, comparing surgery group patients during presurgical versus postsurgical periods, CVEs odds were significantly reduced after surgery (odds ratio = 0.22, 95% CI = 0.08-0.58, p = .002). CONCLUSIONS When added to conservative management, cerebral revascularization surgery appears to reduce the risk of CVEs in patients with SCD-MMS. A prospective study will be needed to validate these findings.
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Northam WT, Slingerland AL, Orbach DB, Smith ER. Magnetic Resonance Imaging/Angiography Versus Catheter Angiography for Annual Follow-up of Pediatric Moyamoya Patients: A Cost Outcomes Analysis. Neurosurgery 2023; 92:1243-1248. [PMID: 36744923 DOI: 10.1227/neu.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/08/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Digital subtraction angiography (DSA) assesses revascularization in pediatric moyamoya patients after surgery, but MRI and angiography (MRI/A) may provide comparable data. OBJECTIVE To evaluate DSA and MRI/A with respect to clinical utility in postoperative follow-up, complication profile, and relative cost at 1 year. METHODS All pediatric moyamoya patients who received bilateral indirect revascularization between 2011 and 2020 were retrospectively reviewed at 1 institution. Patients who underwent MRI/A-only, DSA-only, or both after 1 year were compared. RESULTS Eighty-two patients were included. At 1 year, patients who underwent either MRI/A (n = 29) or DSA (n = 40) had no significant differences in detection rate of new at-risk hypovascular territories (6.9% vs 2.5%, P = .568) or need for subsequent revascularization beyond the mean 40 ± 24-month follow-up period (3.4% vs 5.0%, P > .9). Among patients who underwent both MRI/A and DSA (n = 13), both studies identified the same at-risk territories. No patients experienced MRI/A-related complications, compared with 3 minor DSA-related complications. The use of MRI/A yielded a 6.5-fold reduction in cost per study vs DSA at 1 year. CONCLUSION Using DSA to follow moyamoya patients after indirect revascularization is generally safe but associated with a low rate of minor complications and a 6.5-fold greater financial cost relative to MRI/A. These data support changing practice to eliminate the use of DSA when following routine bilateral moyamoya cases in the absence of clinical symptoms or specific concerns. Using MRI/A as the primary postoperative follow-up modality in this select population provides noninferior care and greater patient access, while reducing cost and potentially decreasing risk.
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Rahman MR, Shen L, Ewen JP, Collard B, Heyes DM, Dini D, Smith ER. Non-equilibrium molecular simulations of thin film rupture. J Chem Phys 2023; 158:2882242. [PMID: 37093990 DOI: 10.1063/5.0149974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/30/2023] [Indexed: 04/26/2023] Open
Abstract
The retraction of thin films, as described by the Taylor-Culick (TC) theory, is subject to widespread debate, particularly for films at the nanoscale. We use non-equilibrium molecular dynamics simulations to explore the validity of the assumptions used in continuum models by tracking the evolution of holes in a film. By deriving a new mathematical form for the surface shape and considering a locally varying surface tension at the front of the retracting film, we reconcile the original theory with our simulation to recover a corrected TC speed valid at the nanoscale.
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Piwowarczyk P, Moyer Q, Mekbib KY, Kappel AD, Zhao S, Shohfi J, Smith H, Orbach D, See AP, Smith ER, Kahle K. 345 Structural Cardiac Defects and Vascular Anomalies in Vein of Galen Malformation Patients: A Multi-Institutional Cohort With Genetic Sequencing. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Mekbib KY, Zhao S, Nelson-Williams C, Prendergast A, Zeng X, Rolle M, Shohfi J, Smith H, Ocken J, Moyer Q, Piwowarczyk P, Allington G, Dong W, van der Ent MA, Chen D, Li B, Duran D, Mane SM, Walcott BP, Stapleton CJ, Aagaard-Kienitz B, Rodesch G, Jackson EM, Smith ER, Orbach D, Berenstein A, Bilguvar K, Zhao H, Erson-Omay Z, King PD, Huttner A, Lifton R, Boggon T, Nicoli S, Jin SC, Kahle K. 169 Exome Sequencing Implicates Endothelial Ras Signaling Network in Vein of Galen Aneurysmal Malformation. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Gupta S, Hauser BM, Catapano J, Farhadi D, Smith ER, Lawton MT, Du R. 348 Risk of Rupture and Treatment Outcomes of Giant Pediatric Aneurysms: Multi-Institutional Case Series and Meta-Meta-Analysis. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Sun LR, Hersh DS, Smith ER, Aldana PR, Jordan LC. Practice variability in the perioperative management of pediatric moyamoya disease in North America. J Stroke Cerebrovasc Dis 2023; 32:107029. [PMID: 36706654 PMCID: PMC10941270 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Revascularization surgery decreases the long-term risk of stroke in children with moyamoya but carries an increased risk of perioperative ischemic events. Evidence-based approaches to safe perioperative management of children with moyamoya are limited. We aimed to understand practice variability in perioperative moyamoya care. METHODS Neurologists, neurosurgeons, and intensivists practicing in North America with expertise in perioperative pediatric moyamoya care participated in a 138-item anonymous survey focused on interdisciplinary perioperative care surrounding indirect revascularization surgery. RESULTS Many perioperative care practices vary substantially between participants. Timing of resumption of antiplatelet therapy postoperatively, choice of sedative agents and vasopressors, goal blood pressures, rate and duration of intravenous fluid administration, and red blood cell transfusion thresholds are among the most variable practices. CONCLUSIONS This practice variability survey highlights several important knowledge gaps and areas of equipoise that should be targets for future investigation and consensus-building efforts.
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Smith ER, Champion de Crespigny PJ, Vally F, Hewitson TD, Toussaint ND, Cade TJ, Holt SG. Cord blood effectively resists mineralization through mechanisms that stabilize calciprotein particles. Kidney Int 2023; 103:782-786. [PMID: 36516910 DOI: 10.1016/j.kint.2022.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
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Zhao S, Mekbib KY, van der Ent MA, Allington G, Prendergast A, Chau JE, Smith H, Shohfi J, Ocken J, Duran D, Furey CG, Le HT, Duy PQ, Reeves BC, Zhang J, Nelson-Williams C, Chen D, Li B, Nottoli T, Bai S, Rolle M, Zeng X, Dong W, Fu PY, Wang YC, Mane S, Piwowarczyk P, Fehnel KP, See AP, Iskandar BJ, Aagaard-Kienitz B, Kundishora AJ, DeSpenza T, Greenberg ABW, Kidanemariam SM, Hale AT, Johnston JM, Jackson EM, Storm PB, Lang SS, Butler WE, Carter BS, Chapman P, Stapleton CJ, Patel AB, Rodesch G, Smajda S, Berenstein A, Barak T, Erson-Omay EZ, Zhao H, Moreno-De-Luca A, Proctor MR, Smith ER, Orbach DB, Alper SL, Nicoli S, Boggon TJ, Lifton RP, Gunel M, King PD, Jin SC, Kahle KT. Genetic dysregulation of an endothelial Ras signaling network in vein of Galen malformations. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.03.18.532837. [PMID: 36993588 PMCID: PMC10055230 DOI: 10.1101/2023.03.18.532837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and severe congenital brain arteriovenous malformation, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP ( RASA1 ) harbored a genome-wide significant burden of loss-of-function de novo variants (p=4.79×10 -7 ). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 ( EPHB4 ) (p=1.22×10 -5 ), which cooperates with p120 RasGAP to limit Ras activation. Other probands had pathogenic variants in ACVRL1 , NOTCH1 , ITGB1 , and PTPN11 . ACVRL1 variants were also identified in a multi-generational VOGM pedigree. Integrative genomics defined developing endothelial cells as a key spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specific EPHB4 kinase-domain missense variant exhibited constitutive endothelial Ras/ERK/MAPK activation and impaired hierarchical development of angiogenesis-regulated arterial-capillary-venous networks, but only when carrying a "second-hit" allele. These results illuminate human arterio-venous development and VOGM pathobiology and have clinical implications.
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See AP, LoPresti MA, Treiber J, Thomas B, Karsten MB, Riordan CP, Scott RM, Lam SK, Smith ER. Morning glory disc anomaly and its implications in moyamoya arteriopathy: a retrospective case series. J Neurosurg Pediatr 2023:1-7. [PMID: 36933265 DOI: 10.3171/2023.2.peds22470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/06/2023] [Indexed: 03/20/2023]
Abstract
OBJECTIVE Morning glory disc anomaly (MGDA), a congenital abnormality of the optic nerve, may be associated with moyamoya arteriopathy, a cerebrovascular abnormality. In this study, the authors aimed to define the temporal evolution of cerebrovascular arteriopathy in patients with MGDA to characterize a rational strategy for screening and management over time. METHODS The records of pediatric neurosurgical patients at two academic institutions were retrospectively reviewed to identify cases of cerebral arteriopathy and MGDA, including radiographic and clinical records documenting patient outcomes of medical and surgical management. RESULTS Thirteen cases of moyamoya syndrome (MMS) associated with MGDA were identified in 13 children aged 0.6-17 years. The pattern of arteriopathy resembled that of non-MGDA MMS, with predominantly anterior circulation involvement. The arteriopathy lateralized with the MGDA, although 3 patients also had contralateral involvement. The overall group was followed for a median of 3.2 years. Radiological biomarkers of cerebral ischemia were applied to guide surgical decisions, and more than half of the patients (7 of 13) had evidence of stroke or progression on serial imaging. Nine patients underwent revascularization surgery, and 4 were managed medically. CONCLUSIONS Cerebral arteriopathy observed in association with MGDA resembles MMS seen in patients without MGDA and is dynamic, with progression observed over months to years and an associated risk of cerebral ischemia that indicates a role for surgical revascularization. Radiological biomarkers may augment clinical data to identify candidates for revascularization surgery.
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Ahtam B, Solti M, Doo JM, Feldman HA, Vyas R, Zhang F, O'Donnell LJ, Rathi Y, Smith ER, Orbach D, See AP, Grant PE, Lehman LL. Diffusion-Weighted Magnetic Resonance Imaging Demonstrates White Matter Alterations in Watershed Regions in Children With Moyamoya Without Stroke or Silent Infarct. Pediatr Neurol 2023; 143:89-94. [PMID: 37054515 DOI: 10.1016/j.pediatrneurol.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/25/2023] [Accepted: 03/12/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Moyamoya is a disease with progressive cerebral arterial stenosis leading to stroke and silent infarct. Diffusion-weighted magnetic resonance imaging (dMRI) studies show that adults with moyamoya have significantly lower fractional anisotropy (FA) and higher mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) compared with controls, which raises concern for unrecognized white matter injury. Children with moyamoya have significantly lower FA and higher MD in their white matter compared with controls. However, it is unknown which white matter tracts are affected in children with moyamoya. METHODS We present a cohort of 15 children with moyamoya with 24 affected hemispheres without stroke or silent infarct compared with 25 controls. We analyzed dMRI data using unscented Kalman filter tractography and extracted major white matter pathways with a fiber clustering method. We compared the FA, MD, AD, and RD in each segmented white matter tract and combined white matter tracts found within the watershed region using analysis of variance. RESULTS Age and sex were not significantly different between children with moyamoya and controls. Specific white matter tracts affected included inferior fronto-occipital fasciculus, inferior longitudinal fasciculus, superior longitudinal fasciculus, thalamofrontal, uncinate fasciculus, and arcuate fasciculus. Combined watershed region white matter tracts in children with moyamoya had significantly lower FA (-7.7% ± 3.2%, P = 0.02) and higher MD (4.8% ± 1.9%, P = 0.01) and RD (8.7% ± 2.8%, P = 0.002). CONCLUSIONS Lower FA with higher MD and RD is concerning for unrecognized white matter injury. Affected tracts were located in watershed regions suggesting that the findings may be due to chronic hypoperfusion. These findings support the concern that children with moyamoya without overt stroke or silent infarction are sustaining ongoing injury to their white matter microstructure and provide practitioners with a noninvasive method of more accurately assessing disease burden in children with moyamoya.
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See AP, Smith ER, Scott RM. Letter: Wide Arterial Sparing Encephalo-Duro-Synangiosis for Moyamoya: Surgical Technique and Outcomes. Oper Neurosurg (Hagerstown) 2023; 24:e391. [PMID: 36921246 DOI: 10.1227/ons.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 01/20/2023] [Indexed: 03/17/2023] Open
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Kahle KT, Duran D, Smith ER. Increasing precision in the management of pediatric neurosurgical cerebrovascular diseases with molecular genetics. J Neurosurg Pediatr 2023; 31:228-237. [PMID: 36609371 DOI: 10.3171/2022.12.peds22332] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023]
Abstract
Recent next-generation DNA and RNA sequencing studies of congenital and pediatric cerebrovascular anomalies such as moyamoya disease, arteriovenous malformations, vein of Galen malformations, and cavernous malformations have shed new insight into the genetic regulation of human cerebrovascular development by implicating multiple novel disease genes and signaling pathways in the pathogenesis of these disorders. These diseases are now beginning to be categorized by molecular disruptions in canonical signaling pathways that impact the differentiation and proliferation of specific venous, capillary, or arterial cells during the hierarchical development of the cerebrovascular system. Here, the authors discuss how the continued study of these and other congenital cerebrovascular conditions has the potential to replace the current antiquated, anatomically based disease classification systems with a molecular taxonomy that has the potential to increase precision in genetic counseling, prognostication, and neurosurgical and endovascular treatment stratification. Importantly, the authors also discuss how molecular genetic data are already informing clinical trials and catalyzing the development of targeted therapies for these conditions historically considered as exclusively neurosurgical lesions.
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Lu VM, Luther EM, Silva MA, Rangwala SD, Starke RM, Smith ER, See AP. The composition of landmark vein of Galen malformation research: the emergence of endovascular treatments. Childs Nerv Syst 2023; 39:733-741. [PMID: 36149485 DOI: 10.1007/s00381-022-05687-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since the advent of endovascular treatment, the long-term prognosis of vein of Galen malformation (VOGM) has markedly improved; however, the nature of research leading to this point is unclear. The objective of this study was to define the composition of VOGM research to date, by means of a bibliometric analysis of the 100 most cited VOGM articles. METHODS An electronic search of Elsevier's Scopus database was performed to identify the 100 most cited articles on VOGM screened against predetermined criteria. Data were then compared. RESULTS The 100 most cited VOGM articles were published between 1974 and 2017 in 38 unique journals and originated from 16 unique countries. Mean citation count and rate were 59.4 citations and 2.9 citations/year, respectively. The USA (n = 42); Hôpital de Bicêtre, France (n = 15); and Dr. Pierre Lasjaunias (n = 16) were the largest individual country, institutional, and author contributors. Compared to the older articles (published < 2000), key differences for newer articles were statistically higher citation rates (P < 0.01), more authors (P < 0.01), higher proportion of endovascular treatment descriptions (P = 0.01), and more originating from Asia Pacific (P < 0.01). CONCLUSIONS From the 100 most cited VOGM articles to date, there has been a noticeable shift from diagnosing VOGM based on the foundational work by Dr. Lasjaunias to understanding how we can model clinical outcomes now that endovascular treatment has become the standard of care. Significant shifts in prognosis are pending, and the current bibliometric data implicate we are on the precipice of more recent works making an impact in the near future.
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Rangwala SD, Albanese JS, Slingerland AL, Papadakis JE, Weber DS, Smith ER, Scott RM, See AP. External validation of the R2eD AVM scoring system to assess rupture risk in pediatric AVM patients. J Neurosurg Pediatr 2023; 31:469-475. [PMID: 36840738 DOI: 10.3171/2023.1.peds22310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/09/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVE The assessment of hemorrhagic risk is of central importance in the management of pediatric brain arteriovenous malformations (AVMs). A recently published scoring system, the R2eD AVM (race, exclusive deep location or not, AVM size < 3 or ≥ 3, venous drainage exclusively deep or not, and monoarterial feeding or >1 arterial feeders) considers patient race and AVM location, size, venous drainage, and arterial supply and was successfully externally validated for use in adults to predict the risk of AVM hemorrhagic presentation. In this study the authors sought to externally validate the R2eD AVM score for prediction of hemorrhagic risk in the pediatric AVM population. METHODS A pediatric database at Boston Children's Hospital was retrospectively reviewed for all patients with a diagnosis of intracranial AVM. Exclusion criteria included age > 21 years, multiple AVMs, and incomplete clinical/radiographic data. Demographic data and R2eD AVM score calculations were collected for all patients. Univariate binary logistic regression and multivariate stepwise backward elimination models were used to determine factors associated with hemorrhagic presentation. RESULTS A total of 212 AVMs were identified in 212 patients with vascular anomalies from 1995 to 2021, and 144 patients met the inclusion criteria (74 [51.4%] male, 111 [77.1%] White), of whom 87 (60.4%) patients presented with rupture and 122 (84.7%) underwent resection. The mean age at surgery was 12 years (range 3 months to 20 years). The R2eD AVM scoring system was applied to each patient. The score components of size < 3 cm and exclusive deep venous drainage were significantly associated with rupture risk (p < 0.05). The complete model for the R2eD AVM score had an area under the curve of 0.671 (95% CI 0.586-0.757). CONCLUSIONS This study demonstrated poor external validity of the R2eD AVM score in predicting pediatric AVM rupture risk. The results suggest that future studies are warranted to determine a better scoring method to capture pediatric rupture risk, given the significant differences in clinical presentation in pediatric compared with adult AVM patients.
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Ahtam B, Feldman HA, Solti M, Doo J, O'Donnell L, Zhang F, Vyas R, Rathi Y, Orbach D, See AP, Smith ER, Grant PE, Lehman LL. Abstract 66: Diffusion Imaging Demonstrates White Matter Alterations In Children With Moyamoya In Watershed Tracts. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Moyamoya is a progressive cerebrovascular disease leading to stenosis of arteries located in the circle of Willis which increases risk of hypoperfusion in specific areas of the brain called watershed regions. Using diffusion weighted magnetic resonance imaging (dMRI), adults with moyamoya have significantly lower fractional anisotropy (FA) and higher mean diffusivity (MD) and radial diffusivity (RD) in their white matter compared to controls. These areas of white matter alterations have been associated with cognitive deficits as well. To our knowledge the examination of combined white matter tracts in the watershed regions of the brain in children with moyamoya has not been previously examined.
Hypothesis:
We hypothesize that children with moyamoya will have higher FA and lower MD and RD in the combined white matter tracts that are in the watershed region compared to control children.
Methods:
We compared a cohort of 15 children with moyamoya with 24 affected hemispheres without stroke to 25 children controls. We analyzed dMRI data using an unscented Kalman filter (UKF) tractography method and extracted major white matter pathways with a fiber clustering method. We compared the FA, MD, axial diffusivity (AD), and RD of the combined watershed white matter tracts using co-variate adjusted ANOVA.
Results:
Age and sex were not significantly different between children with moyamoya and controls. For the combined watershed white matter tracts, children with moyamoya had significantly lower FA and higher MD and RD. AD was also higher but not significant compared to control children (Table 1).
Conclusion:
Lower FA with higher MD and RD is consistent with alterations in white matter tracts concerning for unrecognized white matter injury from hypoperfusion. These dMRI findings could be used as a biomarker for children with moyamoya at risk for cognitive deficits due to hypoperfusion.
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Kappel AD, Lehman LL, Northam WT, See AP, Smith ER. Pediatric Moyamoya Syndrome Secondary to Tuberculous Meningitis: A Case Report. Neurol Clin Pract 2023; 13:e200121. [PMID: 36865644 PMCID: PMC9973290 DOI: 10.1212/cpj.0000000000200121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/02/2022] [Indexed: 01/20/2023]
Abstract
Objectives Tuberculosis is uncommon in the United States and a rare cause of meningitis in children with severe neurologic consequences. Tuberculous meningitis (TBM) is an even rarer cause of moyamoya syndrome with only a handful of cases previously reported. Methods We report the case of a female patient who initially presented at 6 years of age with TBM and developed moyamoya syndrome requiring revascularization surgery. Results She was found to have basilar meningeal enhancement and right basal ganglia infarcts. She was treated with 12 months of antituberculosis therapy and 12 months of enoxaparin and maintained on daily aspirin indefinitely. However, she developed recurrent headaches and transient ischemic attacks and was found to have progressive bilateral moyamoya arteriopathy. At age 11 years, she underwent bilateral pial synangiosis for the treatment of her moyamoya syndrome. Discussion Moyamoya syndrome is a rare but serious sequalae of TBM and may be more common in pediatric patients. The risk of stroke may be mitigated by pial synangiosis or other revascularization surgeries in carefully selected patients.
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Judge J, Kappel AD, Isibor C, OHara J, Larson A, Kleinman ME, Lehman LL, See AP, Smith ER. Abstract TMP21: Association Of A Perioperative Nausea And Vomiting Treatment Protocol With Reduction In Perioperative Strokes In Children And Young Adults With Moyamoya. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Perioperative stroke is a major complication of revascularization surgery in patients with moyamoya. Vomiting is common after neurosurgical procedures and may result in acute changes in intracranial pressure and cerebral blood flow. We instituted a standardized perioperative nausea and vomiting protocol for children and young adults with moyamoya undergoing indirect bypass surgery at our institution.
Hypothesis:
Instituting a standardized perioperative nausea and vomiting protocol will be associated with reduction in the number of perioperative strokes in children with moyamoya undergoing indirect bypass surgery.
Methods:
We retrospectively reviewed consecutive cases of children and young adults with moyamoya who underwent indirect bypass surgery before and after implementation of a new perioperative nausea and vomiting protocol. We compared the rate of strokes in the perioperative period (post-operative day 0 and 1) in the 41 months following implementation (155 surgically treated hemispheres) to 155 surgically treated hemispheres (over 30 months) prior to implementation using Fisher’s Exact test.
Results:
The mean age prior to implementation was 8.7 years (SD 5.5 years) and 9.9 years (SD 6.2 years) post implementation which was not significantly different (p=0.17). In the 30 months prior to initiation of the perioperative nausea and vomiting protocol there were 5 strokes in 155 surgically treated hemispheres (3.2%). After initiation of the protocol, there were no strokes in 155 surgically treated hemispheres (p = 0.03).
Conclusions:
Instituting a standardized perioperative nausea and vomiting protocol was associated with reduction in perioperative strokes in children with moyamoya treated with indirect bypass surgery.
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Tsang C, Nelson J, McCulloch C, Smith ER, Vadivelu S, Akers A, Lee C, Zabramski J, Zafar A, Torbey MT, Morrison L, Awad IA, Kim H. Abstract WP18: Association Of Quality Of Life Domains And Clinical Symptoms In Familial Cerebral Cavernous Malformation Patients. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Familial cerebral cavernous malformation (FCCM) is characterized by multiple brain lesions at risk for intracranial hemorrhage (ICH) and neurological morbidity, affecting quality of life (QoL). PROMIS-29 is a QoL survey validated in some neurological diseases but has not yet been evaluated for FCCM. We aimed to assess whether PROMIS-29 health domains are associated with clinical symptoms in FCCM patients.
Methods:
PROMIS-29 surveys assessing seven QoL domains were completed by 198 FCCM patients >=18 years either at a baseline or follow-up visit in the Brain Vascular Malformation Consortium CCM study. Raw PROMIS-29 domain scores were converted to T scores that are standardized to a reference population with mean 50 and SD 10, and oriented so that higher scores are unfavorable. One-sample t-tests and p-values assessed whether mean T-scores were significantly different from 50 (p<0.05). Multivariable linear regression was used to test whether domain scores were associated with history of ICH, seizures, or headaches at time of survey, adjusting for age and sex.
Results:
Compared to a reference population, FCCM patients had significantly higher anxiety (52.7, 95% CI: 51.3-54.2, p<0.001), pain (52.5, 95% CI: 51.0-54.0, p=0.002), and physical functioning scores (52.0, 95% CI: 51.4-54.5, p<0.001), but lower social participation scores (46.9, 95% CI: 45.4-48.5, p<0.001). History of ICH and headaches were significantly associated with 4 domains each (all >3 points, p<0.05, Table), while seizures were not associated. Fatigue was the only affected domain in common.
Conclusion:
FCCM patients differed significantly from the reference population on anxiety, pain, physical functioning, and social participation domains. These same domains were significantly associated with history of ICH or headaches in patients. Further studies will determine whether changes in health domains are associated with changes in clinical symptoms.
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Shi K, Smith ER, Santiso EE, Gubbins KE. A perspective on the microscopic pressure (stress) tensor: History, current understanding, and future challenges. J Chem Phys 2023; 158:040901. [PMID: 36725519 DOI: 10.1063/5.0132487] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The pressure tensor (equivalent to the negative stress tensor) at both microscopic and macroscopic levels is fundamental to many aspects of engineering and science, including fluid dynamics, solid mechanics, biophysics, and thermodynamics. In this Perspective, we review methods to calculate the microscopic pressure tensor. Connections between different pressure forms for equilibrium and nonequilibrium systems are established. We also point out several challenges in the field, including the historical controversies over the definition of the microscopic pressure tensor; the difficulties with many-body and long-range potentials; the insufficiency of software and computational tools; and the lack of experimental routes to probe the pressure tensor at the nanoscale. Possible future directions are suggested.
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Hewitson TD, Smith ER. Propagation, Culture, and Characterization of Renal Fibroblasts. Methods Mol Biol 2023; 2664:13-29. [PMID: 37423979 DOI: 10.1007/978-1-0716-3179-9_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
The renal fibroblast, and phenotypically related myofibroblast, are universally present in all forms of progressive kidney disease. The in vitro study of the fibroblast, its behaviour, and factors affecting its activity is therefore key to understanding both its role and significance. In this protocol, we describe a reproducible method for selective propagation and culture of primary renal fibroblasts from kidney cortex. Techniques for their isolation, subculture, characterization, and cryogenic storage and retrieval are described in detail.
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